This blog is about the evaluation and treatment of trauma and attachment disorders. It focuses on Dyadic Developmental Psychotherapy; the effective and evidence-based treatment for trauma and attachment disorders.

Apr 23, 2009

Neglect, physical abuse, and sexual abuse (broadly termed, child maltreatment) have profound and long-term effects on a child's development. The long-term effects of chronic early maltreatment within a care-giving relationship (also called Complex Post Traumatic Stress Disorder) of a child can be seen in higher rates of psychiatric disorders, increased rates of substance abuse, and a variety of severe relationship difficulties. Child maltreatment is an inter-generational problem. Most frequently the perpetrators of abuse and neglect are profoundly damaged people who have been abused and neglected themselves.

There are clear links between neglect and abuse and later psychological, emotional, behavioral, and interpersonal disorders. The basis for this linkage is the impact that abuse and neglect have on brain development. Daniel Siegel, medical director of the Infant and Preschool Service at the University of California, L.A., has found important links between interpersonal experiences and neurobiological development.

We know that a child uses the parent's state of mind to regulate the child's own mental processes. It is through a sensitive, responsive, and caring relationship with a primary care-giver that a child develops self-regulation abilities, emotional control, behavioral regulation, and such cognitive abilities as cause-effect thinking, among others. The child's developing capacity to regulate emotions and develop a coherent sense of self requires sensitive and responsive parenting. The National Adoption Center found that 52% of adoptable children have attachment disorder symptoms. In another study, by Cicchetti, & Barnett , 80% of abused or maltreated infants exhibited attachment disorder symptoms. The best predictor of a child's attachment classification is the state of mind with respect to attachment of the birth mother. A birth mother's attachment classification before the birth of her child can predict with 80% accuracy her child's attachment classification at six years of age. That is a remarkable finding. Finally, recent research by Mary Dozier, Ph.D. found that the attachment classification of a foster mother has a profound effect on the attachment classification of the child. She found that the child's attachment classification becomes similar to that of the foster mother after three months in placement. These findings strongly argue for a non-genetic mechanism for the transmission of attachment patterns across generations.

Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average) .

Generally the left hemisphere of the brain is the site of language, motor activity on the right side of the body, and logical thought based on language. The right hemisphere of the brain is responsible for motor activity on the left side of the body, context perceptions, face recognition, interpersonal and emotional processing, and holistic perception. The orbito-frontal cortex (the part of the brain directly behind the eyes) is responsible for integrating emotional responses generated in the limbic system with higher cognitive functions, such as planning and language, in the cerebral cortex's prefrontal lobes. The left orbito-frontal cortex is responsible for memory creation while the right orbito-frontal cortex is responsible for memory retrieval. Healthy functioning requires an integrated right and left hemisphere. A substantial number of synaptic connections among brain cells develop during the first year of life into the middle of the second year of life. An integrated brain requires connections between the hemispheres by the corpus callosum. Abused and neglected children have smaller corpus callosum than non-abused children. Abused and neglected children have poorly integrated cerebral hemispheres. This poor integration of hemispheres and underdevelopment of the orbitofrontal cortex is the basis for such symptoms as difficulty regulating emotion, lack of cause-effect thinking, inability to accurately recognize emotions in others, inability of the child to articulate the child's own emotions, an incoherent sense of self and autobiographical history, and a lack of conscience.

The brains of maltreated children are not as well integrated as the brains of non-abused children. This helps explain why maltreated children have significant difficulties with emotional regulation, integrated functioning, and social development. Conscience development and the capacity for empathy are largely functions of the orbito-frontal cortex. When development in this area of the brain is hindered, there are important social and emotional difficulties. It is very interesting that the orbito-frontal cortex is sensitive to face recognition and eye contact. Maltreated children frequently have disorders of attachment because of their birth-parents lack of sensitive responsive interactions with the child.

Early interpersonal experiences have a profound impact on the brain because the brain circuits responsible for social perception are the same as those that integrate such functions as the creation of meaning, the regulation of body states, the regulation of emotion, the organization of memory, and the capacity for interpersonal communication and empathy. Stressful experiences that are overtly traumatizing or chronic cause chronic elevated levels of neuroendocrine hormones. High levels of these hormones can cause permanent damage to the hippocampus, which is critical for memory. Based on this we can assume that psychological trauma can impair a person's ability to create and retain memory and impede trauma resolution.

Abused and neglected children exhibit a variety of behaviors that can lead to any number of diagnoses. However, the effect of early abuse and neglect on the child can be seen in several critical areas of development. These areas include emotional regulation, behavioral regulation, attachment, biology, response flexibility, a coherent integrated sense of self across time, the ability to engage in affect attunement with significant others (empathy and emotional connectedness), self-concept, cognitive abilities and learning, and conscience development.

The effects of early maltreatment on a child's development are profound and long lasting. It is the impact of maltreatment on a child's developing brain that causes effects seen in a wide variety of domains including social, psychological, and cognitive development. The ability to regulate emotions and become emotionally attuned with another depends on early experiences and the development of specific regions of the brain. Early maltreatment causes deficits in the development of these brain regions, primarily the orbito-frontal cortex and corpus callosum, because of the toxic effects of stress hormones on the developing brain.

These findings strongly suggest that effective treatment requires a sensitive affectively attuned relationship. Siegel stated, "As parents reflect with their securely attached children on the mental states that create their shared subjective experience, they are joining with them in an important co-constructive process of understanding how the mind functions. The inherent feature of secure attachment - contingent, collaborative communication - is also a fundamental component in how interpersonal relationships facilitate internal integration in a child." This has implications for the effective treatment of maltreated children. For example, when in a therapeutic relationship the client is able to reflect upon aspects of traumatic memories and experience the affect associated with those memories without becoming dysregulated, the client develops an expanded capacity to tolerate increasing amounts of affect. The client learns to self-regulate. The attuned resonant relationship between client and therapist enables the client to make sense (a left-hemisphere function) out of memories, autobiographical representations, and affect (right hemisphere functions).

Apr 19, 2009

WASHINGTON -- Schools can no longer drop educational services for special education students while they are suspended from school for violent incidents, under new regulations approved this spring for the 1997 Individuals with Disabilities Education Act. This may become a difficult issue for schools that do not have the resources to continue educating a student in an "alternative setting," as prescribed by the law, American Institutes of Research Senior Research Scientist Mary Magee Quinn says.

Outlining the new rules during the American Federation of Teachers' QuEST '99 Conference, Quinn noted the rules require a school district to continue educating a suspended student in an alternative setting if the suspension lasts longer than 10 days. The students must get all services required for them to continue progressing under their individualized education plans, and any therapies prescribed in the IEP must also be provided as scheduled, the rules state.

The continuation of services rule, as well as several other complexities in the new regulations, helped draw dozens of teachers and other faculty members to hear Quinn speak at the four-day teachers' conference. As deputy director of the Center for Effective Collaboration and Practice, Quinn and her staff have studied the new regulations and consulted with government officials and attorneys to clarify the new rules and help school districts implement the changes. The center also offers extensive information about IDEA '97 and other special education issues on its Internet site: www.air-dc.org/cecp/.

Defining the Problem

Among other confusing issues: determining whether the student's conduct is a manifestation of his or her disability and whether the conduct is part of a larger pattern. For the purposes of determining how a school district can discipline special ed. students who exhibit violent behavior, those questions can determine whether the student is treated like a mainstream student or one who is not accountable for his or her actions. For example, if the student's action is deemed not a manifestation of his or her disability, the student can be suspended for as long as school policy says a general ed. student would be suspended. The difference, however, is the special ed. student must receive educational services after the first 10 days of the suspension.

If the student frequently or repeatedly breaks rules, even if they seem like different rules and separate incidents, the student may be exhibiting a pattern of behavior that calls for a change in his or her IEP, Quinn noted. One red flag that could indicate such a pattern is the repeated suspension of the student. While special ed. students may be repeatedly suspended for up to 10 days at a time for various rule violations, they must be reevaluated if those suspensions constitute a pattern of behavior.

Getting to the Root of the Problem

If a special ed. student is removed for more than 10 cumulative days from school, a functional behavioral assessment must be conducted, according to the law. However, IDEA does not specify what the assessment should be, Quinn said. CECP offers what it calls "best practices" or guidelines to reevaluating students. Quinn also argued IEP teams should take the assessments seriously rather than consider it another mandatory set of forms to fill out to keep a child in school. "If you have to do a functional assessment, you might as well do it to the point where you are actually going to get information you can use from it," she told the teachers. "It's a long process, but it does yield very good information that will make your lives as teachers infinitely easier."In addition to continuing services for suspended special ed. students and reassessing whether their IEPs are appropriate and effective, Quinn said the law requires IEP teams to add a behavioral intervention plan to students' IEPs if they do not already have them. Before IDEA '97, only 8 percent of students with behavioral problems had such intervention plans in place, she said. The intervention plan should be based on conclusions the IEP team draws from the functional behavioral assessment, Quinn said, and should incorporate other people and settings in the child's life besides school. For example, she said, families, peer support programs, speech and language therapists and community agencies, such as religious or community programs, can all reinforce the positive behaviors the IEP team is trying to teach a child.8

Researchers found that treatment with Omega-3 fatty acids was superior to placebo in controlling symptoms autism and associated symptoms including hyperactivity and stereotypy. Amminger and colleagues conducted a double-blind, randomized, placebo-controlled pilot study. The primary outcome measure was a change in scores from baseline to week 6 on the Aberrant Behavior Checklist (ABC).

Cicchetti, D. (2001). The impact of child maltreatment and psychopathology on neuroednocrine functioning. Development and Psychopathology 13, 783-804.

The findings of this study concluded that maltreated children with reported clinical-level internalizing problems have higher cortisol levels compared to non-maltreated boys who had lower levels of cortisol. The findings conclude that maltreatment and different forms of psychopathology have an effect on neuroendocrine regulation.

Chisholm, K. (1998). A Three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages. Child Development, 69 (4), 1092-1106.

This research article examines attachment and indiscriminately friendly behavior in children who spent at least 8 months in a Romanian orphanage (RO). The findings of this research indicate that RO children displayed significantly more insecure attachment behaviors in comparison to the control groups. These children had significantly more indiscriminately friendly behavior, behavior problems, and parents reported more parenting stress.

Results of this study indicated that elevated initial cortisol and epinephrine levels immediately following a traumatic event continued to predict the development of acute PTSD symptoms; particularly in boys.

The purpose of this article is to identify and understand the challenges that mothers face after they adopt special needs children. The study examines adoptive mothers who sought therapeutic assistance after the placement of their child and the difficulties they endured.

According to a recent analysis of data from the Preschoolers with ADHD Treatment Study (PATS), funded by the National Institutes of Health’s National Institute of Mental Health (NIMH), preschoolers who are diagnosed with ADHD and who also have three or more coexisting disorders, are not likely to respond to treatment with the stimulant methylphenidate, regardless of dosage,

The focus of this article is to discuss and review the research concerning physical, cognitive, and emotional development of children adopted from Romanian orphanages over the last 15 years. The trends of early deprivation and possible outcomes are also evaluated.

Research on infants and children who have been maltreated early in life is reviewed to show stress hormone activity. The researchers focus on enhancing care later in development and the possible reversal of the effects on behavior and neurobiology of early experiences. The authors review literature in the field and conclude that the longer the child is neglected the higher degree of developmental delays occur. Studies on the neuroendocrin systems show the effects on the HPA system and CORT systems in response these stressors.

The objective of this study was to evaluate the relationship between levels of self-reported symptoms of depression and anxiety and 24-hour urinary catecholamine excretion. Norepinephrine, epinephrine and cortisol are examined.

The objective of this study was to review the dopamine theory of Attention Deficit Hyperactivity Disorder (ADHD) in terms of the advances made in research over the past decade. Serotonergic agents were found to have a calming affect on psycho-stimulants in which the dopamine transporter (DAT) gene was disrupted.

This article comments on research from the US National Institutes of Health (NIH), which found that women who eat seafood during pregnancy may increase brainpower of their children. The authors list fish oil supplements as an alternative, and found that women who took these supplements during pregnancy had children with better developmental skills.

Oades, R.D. (2005). The control of repsonsiveness in ADHD by catecholamines: evidence for dopaminergic, noradrenergic and interactive roles. Developmental Science, 8 (2), 122-131.

The neurological base of Attention Deficit Hyperactivity Disorder (ADHD) from a neurochemistry and psychopharmacology standpoint, as well as the catecholamine based behavioral systems, are evaluated by Oades and colleagues. Dopamine and noradrenalin neurotransmission to the motor and cognitive symptoms of ADHD were studied.

This article explains the connection that neurotransmitter levels and ratios have on the behavior of at-risk youth. This comprehensive study found that targeted amino acid therapy, in conjunction with scheduled feedings and behavioral interventions, regulated the brain chemistry in children adopted from Russian orphanages.

Authors of this article review empirical findings of neuropsychological functioning in children with Post Traumatic Stress Disorder (PTSD). Serotonin deregulation, cortisol, the limbic system and neuro-imaging techniques are evaluated in regards to brain development.

This article is intended for parents and individuals in the mental health field. It clearly defines the correlation between neglect and abuse early in life and the long lasting effects it has on brain development.

The focus of this article is to provide the audience with background information on attachment, how attachment disorders develop, and why healthy brain chemistry is reflective of healthy attachment in the first two years of life. The author describes what attachment disorders look like in all developmental stages of childhood.

This study found that urinary dopamine and norepinephrine levels were significantly correlated with the severity of PTSD symptoms. The researchers concluded that these findings supported the theory that enhanced sympathetic nervous system (SNS) activation plays a major role in PTSD and that increased SNS arousal may be closely linked to the severity of certain PTSD clusters.

The study team compared views about adoption for two groups of 11-year-old children (n = 180). Their analyses compared the views of children according to their pre-adoption background: UK domestic adoptees placed before the age of six months versus intercountry adoptees who had experienced extreme deprivation for up to three-and-a-half years in Romania prior to placement. Remarkably few differences were found between these groups, with the exception of two areas. Older-placed adopted children from Romania were significantly more likely to find it difficult to talk about adoption than domestic adoptees, and to feel different from their adoptive families. However, supplementary analyses suggested that these differences were due to increased levels of difficulties within the older-placed Romanian group, rather than whether they were adopted internationally or domestically. The implications of the similarities and differences between these groups for policy and practice are discussed.

Support services for the birth relatives of adopted children have received far less research scrutiny than those for adopters and the children themselves. Sellick reports the first stage ‘mapping’ survey of a government commissioned study into birth relative support services and services supporting contact following changes in policy and legislation. The type, range and delivery of such services, commissioned or provided, by local authority and voluntary adoption agencies and adoption support agencies in England and Wales are examined. The survey found that good opportunities exist for linking birth relative and contact support services. However, real challenges remain in promoting support services and reaching birth relatives, and in funding and commissioning such services, particularly from the non-governmental sector.

Clive Sellick is Senior Lecturer in Social Work and Director of International Programmes, School of Social Work and Psychosocial Sciences, University of East Anglia, Norwich

The Child Wise Programme: a course to enhance the self-confidence and behaviour management skills of foster carers with challenging childrenMartin Herbert and Jenny Wookey

Looked after children with a history of maltreatment and abandonment are prone to develop high rates of mental health difficulties. They tend to suffer from multiple impairments, sometimes involving cognitive deficits and extremes of antisocial behaviour. Foster carers' management skills and emotional resources are tested to the limit. A further concern is the contribution of challenging behaviour to the unplanned termination of foster placements. Carers, if they are not to feel deskilled by the increasing numbers of children with special needs placed with them, require a more focused preparatory and follow-up training than they usually receive. This study questioned whether a broadly based cognitive behavioural programme could, by increasing carers’ behaviour management skills and self-assurance, reduce the challenging behaviour of looked after children and the resultant instability of placements. The answers were sought from a randomised controlled study of foster carers attending the parent training Child Wise Programme (CWP) designed by the authors. The programme combines course leaders’ professional experience of working with challenging children and parent groups, and foster carers’ personal expertise based on living with and caring for challenging children.

The intervention, with an experimental group of 67 foster carers and a comparative waiting-list control group of 50 carers, succeeded in meeting just over half of its key aims. An increase in the confidence of the carers was a significant gain. Also positive was the majority of personal reports indicating improvements in looked after children's behaviour, changes generally attributed to the acquisition of new behaviour management skills. Although some of the statistical comparisons were disappointing in their failure to reach significant levels (eg the reduction in placement breakdowns), they provided useful information about ways of improving the training. Qualitative methods were used to explore the subjective responses of participants to the Webster-Stratton and Herbert (1994) collaborative style of training employed. These produced valuable insights into the personal and professional dilemmas of a foster carer's role, as well as data which contributed to the evaluation of the training programme.

Martin Herbert is Emeritus Professor in Clinical and Community Psychology atExeter University, and Honorary Consultant Psychologist at the Royal Devonand Exeter NHS Health Care Trust

Jenny Wookey is a Consultant Clinical Psychologist at the Plymouth HospitalsNHS Trust, and a Supervisor for the Clinical Psychology Doctoral courses atPlymouth and Exeter Universities

The Hope Connection: a therapeutic summer day camp for adopted and at-risk children with special socio-emotional needsKaryn B Purvis, David R Cross, Ron Federici, Dana Johnson and L Brooks McKenzie

Large numbers of North American and Western European families are adopting children with serious socio-emotional needs. Other children experience similar deficits as a result of neglect and abuse by carers. Often these children are diagnosed with psychopathology and receive drug treatments that can be ineffective and even detrimental. The authors report on The Hope Connection, a project designed to meet the needs of these at-risk children and their families. Its core is a theoretically integrated summer day camp offering activities that are attachment rich, sensory rich and behaviourally structured. Pre-test and post-test data indicate that summer camp had a significant impact on the children’s behaviour (n = 19), as indicated by parent-report measures of child behaviour problems and attachment. These findings are discussed with regard to possible future directions of programmeme implementation and evaluation.

Karyn B Purvis and David R Cross are Associate Directors of the Institute of Child Development, and Professors of Psychology, and L Brooks McKenzie is an MA-Doctoral student, Texas Christian University

Ron Federici is a Neuropsychologist, Federici & Associates

Dana Johnson is Director of the Division of Neonatology and Director of the International Adoption Clinic, University of Minnesota

Inside the foster family: what research tells us about the experience of foster carers’ childrenRobert Twigg and Tracy Swan

Key words: Foster carers’ children, foster family, foster care

Although foster care is the main source of out-of-home care for children and young people, little is known about the dynamics of the foster family. This article focuses on one subsystem of the foster family system, the foster parents’ own children. Fourteen research studies (nine published, five unpublished) were reviewed which involved approximately 232 respondents ranging in age from seven to 32 when interviewed and including nearly equal numbers of males and females. Findings include benefits of fostering, impact of fostering on foster carers’ children, responses to loss of role and parental attention, and the impact of the child welfare or foster care system. The authors conclude with several recommendations designed to make fostering a more positive experience.

Robert Twigg is Associate Professor, Faculty of Social Work, University of Regina, Canada

Tracy Swan is Assistant Professor, Memorial University of Newfoundland, Canada

Training and experience: keys to enhancing the utility for foster parents of the Assessment and Action Record from Looking After ChildrenSarah Pantin and Robert Flynn

The Looking After Children (LAC) approach is now widely used internationally in child welfare. The approach, which originated almost two decades ago, aims systematically to raise the standard of corporate parenting and improve the outcome of young people in out-of-home care. The Assessment and Action Record (AAR) from LAC is used to monitor young people’s developmental progress on a year-to-year basis. Clearly, foster carers are central to the successful implementation of LAC and it is important that they perceive the AAR to be useful in carrying out their fostering duties. Previous research in the UK and Australia found that foster carers believed the Record to be useful, especially if they were just getting to know the child or if the child had been in multiple placements. The study reported here draws on survey information provided by 93 foster carers in the province of Ontario, Canada. The authors found that foster carers who had received what they saw as higher-quality training rated the AAR as being more useful in their work. Interestingly, however, the amount of experience they had had in using the instrument was unrelated to their ratings of its usefulness. Overall, high-quality training emerged as a central feature of effective implementation. Specific recommendations were made in relation to LAC training curriculum requirements and stakeholder involvement.

Sarah Pantin is a graduate of the Clinical Psychology programme, University of Ottawa, Canada

Robert Flynn is Professor of Psychology and Director of the Centre for Research on Educational and Community Services at the same university

Apr 10, 2009

A great resource is the Psychology Wiki. Since this is administered by identified persons and experts, not just anyone who wants to edit and administer, the material is much more reliable and vetted. There are excellent articles there about

If you've not seen the Parent Manual at www.attach.org, take a look. It is a great resource for parents and professionals. It contains hundreds of specific and useful examples; all consistent with the ATTACh White Paper on Coercion and with the various practice principles of the APA, NASW, APSAC, etc.

Apr 6, 2009

In exciting new developments, researchers at SUNY Downstate Medical Center in Brooklyn, NY have shown that they could erase memories using a single substance in a single does. This may lead to being able to eliminate traumatic memories and the effects of Complex Trauma and PTSD. The substance appears to block the activity of a substance that the brain needs to retain information and memories. While the practical applications of this new research to humans in years or decades away, it shows the great advances that research into brain functioning are beginning to yield practical results.

Apr 5, 2009

The new book, Treating Complex Traumatic Stress Disorder, edited by Christine Courtois and Julian Ford, The Guilford Press, NY, 2009, supports the various elements, principles, and techniques of Dyadic Developmental Psychotherapy. The chapter on family therapy approaches states, "Meta-analytic studies have found family based treatments to be more effective than treatment as usual (TAU)...The strongest evidence for the efficacy of family therapy for traumatic stress disorders is provided by studies with families of traumatized toddlers and preschool- or early elementary school-aged children." pp394-395.

The book describes the importance of affect regulation, focusing on attachment relationships in treatment, attention to developmental level and processes, emotional regulation, titrated exposure to traumatic memories, therapeutic alliance, intersubjectivity, and other topics that are core principles and methods of Dyadic Developmental Psychotherapy. It is heartening to find additional support for the use of DDP in the treatment of attachment and trauma disorders.

The book describes practice principles for treating children with complex traumatic stress disorder which are quite consistent with previous material published about DDP over the last several years:1. Safety First2. A relational bridge must be developed to engage, retain, and maximally benefit the child and caregiver(s).3. Diagnosis, treatment planning, and outcome monitoring are always relational.4. Diagnosis, treatment planning, and outcome monitoring are always strengths-based.5. All phases of treatment should aim to enhance self-regulation competencies.5a. Emotional regulation.5b. Attention, memory, decision making (information processing).5c. Self-regulation of consciousness and motivation.5d. Bodily self-regulation.5e. Relational self-regulation.6. Determining with whom, when, and how to address traumatic memories.7. Preventing and managing relational discontinuities and psychosocial crises.from pages 67-78.As described and elaborated in the book, these principles have also been previously described and elaborated on in various publications about DDP (several books and journal articles).

Arthur Becker-Weidman, CSW-R, PhD.DABPS received his doctorate in Human Development from the University of Maryland, Institute for Child Study. He achieved Diplomate status from the American Board of Psychological Specialties in Child Psychology and Forensic Psychology. He is a member of the American College of Forensic Examiners.

Dr. Becker-Weidman has over twenty years experience as a family therapist, consultant, and researcher. He has directed mental health, addiction treatment, family service, and other behavioral health organizations.

Dr. Becker-Weidman has extensive experience counseling families and helping them through difficult times with practical advice. He has published over a dozen scholarly papers and presented at numerous national, regional, and local professional meetings. Much of his research and publications have focused on adolescent and adoptive family development.